Anxiety Disorders and Medications

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					Anxiety Disorders and
    Medications
              Anxiety and Fear
• Anxiety
   – Future-oriented mood state
   – Characterized by marked negative affect
   – Somatic symptoms of tension
   – Apprehension about future danger or misfortune
• Fear
   – Present-oriented mood state, marked negative affect
   – Immediate fight or flight response to danger or threat
   – Strong avoidance/escapist tendencies
   – Abrupt activation of the sympathetic
   – nervous system
             Anxiety Disorders
• Anxiety and fear are normal emotional states; however,
  anxiety may start to cause distress and hinder normal
  functioning.

• Are among most diagnosed disorders found in DSM.

• Represent a broad heterogeneous group of problems.
  For example, Specific Phobia can be conditioned
  …Social Phobia appears to have strong genetic
  component…PTSD can be brought on by single event.
                Anxiety Symptoms
• Anxiety symptoms equated w/ “neurosis”-
  phobias, indecision, panic, gastric
  problems.
• In past, anxiety disorders were not viewed
  as serious disorders…viewed as normal
  and protective.
  Example- if I am taking a test a little
  anxiety is helpful (Conversely, depression is rarely seen
  as benign0.
   Yerkes-Dodson Law (1908)
• Describes a relationship between anxiety
  and performance.
• As person becomes a bit more tense and
  alert- performance of skilled tasks
  improves.
• Then it plateaus
• Beyond this, it interferes w/ performance.
            Current Thought
• However, current conceptualization is to see
  them as more serious and chronic.
• One problem is comorbidity
  – About half of anxiety patients have > 2 or more
    secondary diagnoses
  – Major depression is the most common secondary
    diagnosis
  – Comorbidity suggests common factors across anxiety
    disorders
  – Anxiety and depression are closely related
         Anxiety Disorders
• Generalized Anxiety Disorder
• Panic Disorder with and without
  Agoraphobia
• Specific Phobias
• Social Phobia
• Posttraumatic Stress Disorder
• Obsessive-Compulsive Disorder
Anxiety/Cognition/Personality
Andrews et al (1994)- see adversity as the
trigger stimulus to arousal leading to symptoms.
Arousal dependent on 2 factors:
1) appraisal (perception of degree of
   threat)
2) the extent to which the individual
   responds w/ high arousal (how reactive
   is nervous system?)
 Item 2 suggests a “personality” characteristic
              Trait Anxiety
• Psychologists like Hans Eysenck,and
  Charles Spielberger (State-Trait Anxiety
  Inventory) see proneness to anxiety as a
  stable personality trait that could influence
  behavior.
• STAI determines anxiety in a specific
  situation and as a general trait.
    Trait Anxiety and Appraisal
 Trait Anxiety implies differences between people
  in the disposition to respond to stressful
  situations with varying amounts of State Anxiety.
 Whether or not people who differ in T-Anxiety
  will show corresponding differences in S-Anxiety
  depends on the extent to which each of them
  perceives a specific situation as psychologically
  dangerous or threatening,
             Fight or Flight
• Hard-wired nerve pathway system for
  adaptive dealing w/potential danger.
• When triggered initiates a multilevel
  neurochemical and hormonal reaction.
• Nonessential physiological processes
  (e.g., digestion) shut down.
• Stressful event perceived at cortical level
  (or hijacked by Amygdala)
             Fight or Flight
• Lower brain put on alert- “limbic alert.”
• Locus coeruleus has role here since LC
  nerve cells project in to limbic system and
  a burst of cell excitation leads to limbic
  activation.
• Limbic system and hypothalamus impact
  Pituitary and other endocrine glands and
  sympathetic nervous system.
• Body now prepared to deal w/ stressor
        Anxiety Medications
• First Benzodiazepine- Librium 1957
• Used as sedative (anxiety) and hypnotic
  (insomnia)
• Benzos were much better at reducing
  anxiety than previous meds- barbiturates
  such as Miltown and Doriden amongst
  others
• More importantly less lethality in overdose
         Benzos for Anxiety
• For anxiety:
  Valium
  Librium
  Ativan
  Tranxene
  Xanax
         Benzos for Insomnia
•   Restoril
•   Dalmane
•   Ambien
•   Halcion
                 Half-Life
• One of the main differences between
  different benzodiazepines is the half-life
• Amount of time serum level reduced by
  half
• Those with longer half-life tend to build up
  quicker
• This becomes important if liver is
  deceased
     Types of Anti-anxiety Drugs
•   Benzodiazepines
•   Atypical Benzos
•   Buspirone
•   Anthitamines
•   Beta Blockers
•   Clonidine
•   Gabitril
                Benzos
• Interact w/ benzo receptors
• Several types of benzo receptors
• Current meds are not selective as to type
• Heavy concentration of benzo receptors in
  limbic system
• Binding of a benzo at BZ receptor
  enhances the effect of GABA
  neurotransmitter
       GABA & Chloride Ions
• Chloride ion channels appear on the
  surface of many nerve cells.
• They carry a slight negative charge.
• These ion channels can be activated
  (opened)
• They are opened when stimulated by
  GABA.
• Negative ions are drawn in to the cell
       GABA & Chloride Ions
• Cells electrical characteristics are altered
  resulting in decreased excitability.
• This works as a braking system
  dampening “limbic alert”
• Calms overall brain excitation…calming
  effect…reduce anxiety
   The Anxiety Disorders: An
           Overview
• Generalized Anxiety Disorder
• Panic Disorder with and without
  Agoraphobia
• Specific Phobias
• Social Phobia
• Posttraumatic Stress Disorder
• Obsessive-Compulsive Disorder
              Generalized Anxiety Disorder:
              The “Basic” Anxiety Disorder
• Overview and Defining Features
   – Excessive uncontrollable anxious apprehension and worry
   – Coupled with strong, persistent anxiety
   – Somatic symptoms differ from panic (e.g., muscle tension,
     fatigue, irritability)
   – Persists for 6 months or more
• Facts and Statistics
   – GAD affects 4% of the general population
   – Females outnumber males approximately 2:1
   – Onset is often insidious, beginning in early adulthood
   – Tendency to be anxious runs in families
       Generalized Anxiety Disorder:
     Associated Features and Treatment

• Associated Features
  – Persons with GAD -- Called “autonomic
    restrictors”
  – Fail to process emotional component --
    thoughts / images
• Treatment of GAD
  – Benzodiazapines – Often prescribed
  – Psychological interventions – Cognitive-
    Behavioral Therapy
      Panic Disorder with and without Agoraphobia

• Overview and Defining Features
   – Experience of unexpected panic attack – A false alarm
   – Anxiety, worry, or fear about having another attack
   – Agoraphobia – Fear or avoidance of situations/events
   – Symptoms and concern persists for 1 month or more
• Facts and Statistics
   – Panic disorder affects about 3.5% of the population
   – Two thirds with panic disorder are female
   – Onset is often acute, beginning between ages 25 -29
        Panic Disorder: Associated Features and
                       Treatment
• Associated Features
   – Nocturnal panic attacks – 60% panic during non-REM sleep
   – Interoceptive/exteroceptive avoidance, catastrophic
     misinterpretation of symptoms
• Medication Treatment of Panic Disorder
   – Target serotonergic, noradrenergic, and benzodiazepine
     GABA systems
   – SSRIs (e.g., Prozac and Paxil) – Preferred drugs
   – Relapse rates are high following medication discontinuation
• Psychological and Combined Treatments of Panic Disorder
   – Cognitive-behavior therapies are highly effective
   – No long-term advantage for combined treatments
   – Best long-term outcome – Cognitive-behavior therapy alone
           Specific Phobias: An Overview

• Overview and Defining Features
   – Extreme and irrational fear of a specific object or
     situation
   – Markedly interferes with one's ability to function
   – Recognize fears are unreasonable
   – Still go to great lengths to avoid phobic objects
• Facts and Statistics
   – Affects about 11% of the general population
   – Females are again over-represented
   – Phobias run a chronic course
   – Onset beginning between 15 and 20 years of age
      Specific Phobias: Associated Features and
                      Treatment
• Associated Features and Subtypes of Specific Phobia
   – Blood-injury-injection phobia – Vasovagal response
   – Situational phobia – Public transportation or enclosed
     places (e.g., planes)
   – Natural environment phobia – Events occurring in nature
     (e.g., heights, storms)
   – Animal phobia – Animals and insects
   – Other phobias – Do not fit into the other categories (e.g.,
     fear of choking, vomiting)
   – Separation anxiety disorder – Children’s worry that
     something will happen to parents
             Specific Phobias: Associated
            Features and Treatment (cont.)

• Causes of Phobias
   – Biological and evolutionary vulnerability, direct
     conditioning, observational learning, information
     transmission

• Psychological Treatments of Specific Phobias
   – Cognitive-behavior therapies are highly effective
   – Structured and consistent graduated exposure
               Social Phobia: An Overview
• Overview and Defining Features
   – Extreme and irrational fear/shyness
   – Focused on social and/or performance situations
   – Markedly interferes with one's ability to function
   – May avoid social situations or endure them with distress
   – Generalized subtype – Anxiety across many social
     situations
• Facts and Statistics
   – Affects about 13% of the general population at some point
   – Females are slightly more represented than males
   – Onset is usually during adolescence
   – Peak age of onset at about 15 years
  Social Phobia: Associated Features and Treatment

• Causes of Phobias
   – Biological and evolutionary vulnerability
   – Direct conditioning, observational learning,
     information transmission
• Medication Treatment of Social Phobia
   – Beta blockers – Not that useful
   – Tricyclic antidepressants -- Reduce social anxiety
   – Monoamine oxidase inhibitors – Reduce reduce
     anxiety
   – SSRI Paxil – FDA approved for social anxiety
     disorder
   – Relapse rates – High following medication
     discontinuation
   Social Phobia: Associated
    Features and Treatment
             (cont.)
• Psychological Treatment of Social Phobia
  – Cognitive-behavioral treatment – Exposure,
    rehearsal, role-play in a group setting
  – Cognitive-behavior therapies are highly
    effective
     Posttraumatic Stress Disorder (PTSD): An Overview

• Overview and Defining Features
  – Requires exposure to a traumatic event
  – Person experiences extreme fear, helplessness, or horror
  – Continue to re-experience the event (e.g., memories,
    nightmares, flashbacks)
  – Avoidance of reminders of trauma
  – Emotional numbing
  – Interpersonal problems are common
  – Markedly interferes with one's ability to function
  – PTSD diagnosis – Only 1 month or more post-trauma
Posttraumatic Stress Disorder
(PTSD): An Overview (cont.)
• Facts and Statistics
  – Affects about 7.8% of the general
    population
• Most Common Traumas
  – Sexual assault
  – Accidents
  – Combat
            Posttraumatic Stress Disorder (PTSD):
              Causes and Associated Features
• Subtypes and Associated Features of PTSD
   – Acute PTSD – May be diagnosed 1-3 months post trauma
   – Chronic PTSD – Diagnosed after 3 months post trauma
   – Delayed onset PTSD – Symptoms begin after 6 months or
     more post trauma
   – Acute stress disorder – Diagnosis of PTSD immediately
     post-trauma
• Causes of PTSD
   – Intensity of the trauma and one’s reaction to it
   – Uncontrollability and unpredictability
   – Extent of social support, or lack thereof post-trauma
   – Direct conditioning and observational learning
Posttraumatic Stress Disorder
     (PTSD): Treatment
• Psychological Treatment of PTSD
  – Cognitive-behavioral treatment involves
    graduated or massed imaginal exposure
  – Increase positive coping skills and social
    support
  – Cognitive-behavior therapies are highly
    effective
 Obsessive-Compulsive Disorder (OCD): An Overview

• Overview and Defining Features
• Obsessions
   – Intrusive and nonsensical thoughts, images, or
     urges that one tries to resist or eliminate
• Compulsions
   – Thoughts or actions to suppress thoughts
   – Provide relief
• Most persons with OCD display multiple obsessions
• Many with cleaning, washing, and/or checking rituals
        Obsessive-Compulsive Disorder (OCD):
          Causes and Associated Features
• Facts and Statistics
   – Affects about 2.6% of the population at some point
   – Most persons with OCD are female
   – OCD tends to be chronic
   – Onset is typically in early adolescence or adulthood
• Causes of OCD
   – Parallel the other anxiety disorders
   – Early life experiences and learning that some thoughts are
     dangerous/unacceptable
   – Thought-action fusion – The thought is like the action
  Obsessive-Compulsive Disorder (OCD): Treatment

• Medication Treatment of OCD
   – Clomipramine and other SSRIs – Benefit about
     60%
   – Psychosurgery (cingulotomy) – Used in extreme
     cases
   – Relapse is common with medication
     discontinuation
• Psychological Treatment of OCD
   – Cognitive-behavioral therapy – Most effective for
     OCD
   – CBT involves exposure and response prevention
   – Combined treatments – Not better than CBT alone